Large neck metastasis with unknown primary tumor - a case report

Abstract

Introduction. Metastatic head and neck carcinoma from an unknown primary\n tumor is defined as a metastatic disease in the neck?s lymph nodes without\n evidence of a primary tumor after appropriate investigation. Multiple\n national guidelines recommend that essential steps in diagnostic protocols\n involve a detailed clinical exam with radiological imaging, fine-needle\n aspiration (FNA) biopsy of the cervical tumor, panendoscopy with palatine\n and lingual tonsillectomy, immunohistochemical staining, and human\n papillomavirus (HPV) detection. Treatment of head and neck carcinomas of\n unknown primary (CUPs) origin involves surgery (neck dissection) with\n radiotherapy, while some authors recommend chemo-radiotherapy in cases of\n the advanced regional disease. Case report. A 44-year old male was referred\n to the tertiary medical center because of a large ulcero-infiltrative\n cervical mass on the right side. Examination of the head and neck and\n flexible nasopharyngolaryngeal endoscopy was conducted, followed by computed\n tomography (CT) of the head, neck, and thorax with intravenous contrast. The\n primary localization of the tumor was not confirmed by these diagnostic\n methods. Open biopsy of the neck mass confirmed histopathology diagnosis of\n metastatic squamous cell carcinoma. Results of panendoscopy with biopsies\n and bilateral tonsillectomy were negative for malignancy. Treatment included\n extended radical neck dissection with reconstruction and postoperative\n ipsilateral radiotherapy. Five years after the first surgery, the patient\n presented with an extensive pharyngolaryngeal tumor. Biopsy with\n histopathology examination confirmed the diagnosis of squamous cell\n carcinoma. Conclusion. A structured step-by-step diagnostic approach in\n identifying the primary site of the metastatic head and neck carcinoma is\n mandatory. Substantial advances in diagnostics and operative techniques have\n increased the likelihood of primary tumor identification, as well as\n detection of regional and systemic spread of the disease. Purpose of\n adherence to guidelines results in higher overall-survival and longer\n regional disease-free survival in these patients.